CHAPTER V.

CASES OF DIFFICULT LABOR.

I wish to give you so much instruction in regard to cases of difficult labor that you may at least be prepared to decide in any case when the services of a physician is indispensably necessary, to decide whether the parturition in a given case is a natural one that does not need any assistance, or an unnatural one requiring the assistance of the art of midwifery, scientific or manual, for the relief of irregularities and difficulties. In general I shall adopt Churchill’s divisions and definitions as I think they are very concise and correct.

TEDIOUS LABOR.

“DEFINITION. The head of the child presents and the labor is terminated without manual or instrumental assistance, but it is prolonged beyond twenty-four hours from causes which occasion delay in the first stage.”

Prolongation of labor is of comparatively small consequence when the membranes are still intact, as they serve to protect the soft parts of the mother as well as the body of the child from injurious pressure, but the mere lengthening of the labor may become a serious thing when the head has entered the pelvis, when the uterus is strongly excited by reflex stimulation, and when the maternal soft parts as well as the fœtus and cord are exposed to severe pressure. When we find no evil resulting from the delay we need not interfere, but when we can remove the cause of it we are bound to do so.

In tedious labors the woman becomes fatigued, the loss of sleep is much felt, her spirits become depressed, and the stomach is more or less disturbed, but when the other bodily functions are performed regularly, the skin is cool, the pulse quiet, the tongue clean and moist, there is no headache, and the pains recur tolerably regularly, the condition of the patient is favorable, though the pains are inefficient and vary in their duration and frequency. There is usually loud outcry during the pain in the first stage of labor, but there is often sufficient remission of the suffering for the woman to get some quiet sleep, and generally there is progress to the labor.

INEFFICIENT ACTION OF THE UTERUS occurs most commonly in women confined for the first time, and sometimes we can ascribe it to no cause but constitutional peculiarity, or a deranged state of the digestive organs, or mental depression; in other cases it may be caused by irritation of the os and cervex uteri.

The skilled nurse may properly send for a medical man, though he is not indispensably necessary in such cases. The best thing which she can give in such cases is a quarter grain dose of morphine to suspend the pains and induce sleep, or if this is not thought best it may be proper to give physic or stimulating enemata. Never give ergot to increase the pains, but it may be proper to give several grains of quinine. However, giving medicine must be left as much as possible to the physician.

EXCESSIVE AMOUNT OF LIQUOR AMNII with undue distention of the uterus in some cases renders the pains inefficient. The unusually large size, and the fluctuation of the abdominal tumor may be obvious, but although an accoucheur might deem it advisable to evacuate the waters, the skilled nurse who could not be certain that there was a favorable presentation, should not do it. She must exercise patience herself and encourage the patient to do so, and time will probably do the work, though it is better to commit the case to a doctor.

AN UNDILATABLE OS UTERI, which remains rigid although the pains are severe, may sometimes be felt with its edges thin and stretched over the head, and sometimes thick and tough. In the majority of cases patience and time may overcome the obstacle, but as it is best in some cases to give chloroform, chloral, &c., and in some instances to use local means to relax or dilate the os, the physician should be sent for. The nurse may properly give the patient a hip bath.

PREMATURE ESCAPE OF THE LIQUOR AMNII and OBLIQUITY OF THE UTERUS are both causes of tedious labor, but not cause for apprehension or special interference. I have already given some hints in regard to the treatment of the latter class of cases.

THE POSTERIOR LIP OF THE CERVIX UTERI IN SOME INSTANCES IS RETRACTED WHILE THE ANTERIOR IS DRAWN TIGHTLY OVER THE CROWN OF THE HEAD. In such cases it has been my practice to draw with my finger the anterior lip forward, and during the time of the pain to press my finger against the head of the child. I do this believing that the anterior lip is caught between the head and symphasis pubis, and that it will be better retracted while support is given to the head.

POWERLESS LABOR.

“DEFINITION. The labor is prolonged in the second stage by causes which act on the uterine powers primarily or secondarily, rendering the pains feeble and inefficient or totally suppressing them.” In consequence of the stage at which the delay takes place, certain symptoms arise which render speedy delivery imperative.

The second stage may continue twenty hours or more without any bad symptoms, but usually if it exceeds twelve hours some of the following symptoms may be observed: The pains become irregular as to recurrence and force—perhaps become weaker—there may be rigors or shiverings—the vomiting may be distressing—there may be constant restlessness and fever—the vagina and uterus may be hot and tender to the touch—and the pressure of the child’s head may prevent the evacuation of the bladder. The same causes (weak constitution, mental emotion, disease, &c.), which in the first stage rendered the labor tedious without bad symptoms, now occasion these and perhaps even more alarming indications. If an experienced accoucheur now arrives to take charge of the case he will be likely to apply the forceps, but it would have been better if he had been there and applied them sooner, before the patient had undergone so much suffering; and the midwife who attends a woman in the first stage of the labor should ascertain if any of the following causes of powerless labor exists: Is there a weak constitution or one exhausted by disease? Is it a first labor and the woman of advanced age? Has the patient had very many children? Is there excess of liquor amnii? Is there malposition of the uterus? No midwife should undertake to manage such a case alone.

OBSTRUCTED LABOR.

“DEFINITION. The progress of the labor is impeded by some mechanical obstruction in the passages connected with the soft parts, which by causing delay in the second stage leads to the developement of symptoms of powerless labor.”

The symptoms that arise and that cause anxiety are the same as in a case of powerless labor, except that while in the latter kind the pains are feeble, in the case of obstructed labor the pains may be vigorous and severe but ineffective in consequence of obstacles. I may say, however, that these obstacles have not been often met with in my practice. Since I commenced the practice of midwifery three thousand cases of pregnancy have been under my observation for treatment, and I have not yet met with any of the following causes of obstructed labor: Occlusion of the os uteri, cancer of the os uteri, undilatable vagina, tumors in the pelvis, or diseased ovary, stone in the bladder, imperforate hymen, hernial protrusion into the vagina, or blood effusions, or swelling of the soft parts. I have met with one case of excessive œdematous effusion of the vulva, which I relieved by puncturing the skin; one case of cystocele which I relieved by first drawing the water and then returning the bladder, before the head of the child descended into the pelvis; one case of ovarian tumor that was not at that time in the pelvis; one case of small fibrous tumor on the neck of the uterus, which did not much obstruct the labor; and numerous cases where hardened feces in the rectum was an obstacle until they were removed by the use of enemata. In cases of obstructed labor the skilled nurse will show her wisdom by detecting the obstructions and sending for an accoucheur.

DEFORMED PELVIS.

“DEFINITION. The progress of the labor impeded by abnormal deviations in the form of the pelvis, giving rise to delay in the second stage, or rendering the descent of the child impossible without assistance, or altogether impracticable. The symptoms are those of powerless labor.”

The EQUALLY ENLARGED PELVIS, enlarged in all its parts, is not often met with, and is of no obstetric importance. If in any case this condition is diagnosed preceding or during labor, the patient should be watched by the nurse lest labor close so precipitately that the child falls to the ground.

THE EQUALLY CONTRACTED PELVIS—equally contracted in all its diameters, generally renders the labor difficult and tedious but not impracticable, by the natural powers. Other distortions such as has often been caused by rickets, &c., offer great obstruction to the passage of the child. In some cases a modification of the position of the child allows it to descend, but in many cases it is necessary to interfere and terminate the labor artificially. The nurse should not wait for unfavorable symptoms to appear before she sends for a man that is able to use the forceps, &c.

MALPOSITION AND MALPRESENTATION OF THE CHILD.

Unnatural or abnormal labor may be caused by some peculiarity on the part of the child, in the position or presentation. These cases demand the services of the skilled accoucheur, and I do not intend to hint that the nurse should ever attempt to do what an educated physician should be called to do in these cases.

FACE PRESENTATIONS sometimes retard the labor so much in the second stage as to give rise to unfavorable symptoms. In cases where the action of the uterus is so energetic as to finally expel the child, the sufferings of the mother are severe and prolonged. I have in my practice met with four cases, three of which were delivered by the natural powers, the children living; in one case craniotomy was performed. The mothers all lived. The diagnoses of face presentations is not easy at an early stage of labor. The finger first touches the forehead, which may be mistaken for the vertex. When the membranes are ruptured we may be able to make out the presentation. We may distinguish the edges of the orbits, the prominence of the nose, the mouth, &c. The bridge of the nose is the best guide, it being prominent, firm, and unlike any part of the breech or vertex. The face becomes tumefied during the labor, and the cheeks pressed together to resemble the nates, and it may be mistaken for a breech presentation. But in either presentation the proper course for the nurse is to leave the case alone in the expectation that the natural efforts will be sufficient to complete delivery. The child when born has a frightful appearance from the swelling and discoloration of one cheek, &c., but the injuries pass away in a day or two.

THE FOREHEAD TOWARDS THE ARCH OF THE PELVIS at the time of delivery is not favorable, but unless the pelvis is proportionately small no interference is necessary.

The BREECH may present at the brim in different positions, and the breech is distinguished by its roundness and softness, by the cleft between the buttocks, by the arms and by the organs of generation. In some cases the labor is concluded as quickly as if the head descended, in others it is more tedious. The results as regards the mother are as favorable as in head presentations. The danger to the child is in direct proportion to the length of time between the birth of the body and that of the head.

When the body is expelled so far as the umbilicus, the danger to the child commences, for at this time the cord may be pressed between the body of the child and the pelvic walls. A loop of the cord should be pulled down, and if it freely pulsates the child can probably be delivered alive. Generally a judicious traction on the part of the accoucheur, combined with firm pressure through the abdomen applied by an assistant, will effect delivery of the head before the delay has had time to prove injurious to the child. If the arms of the child are above at the side of the head, the doctor will bring one down by passing a finger over the shoulder as near as possible to the elbow, and then drawing it across the face and chest until it arrives at the external orifice, but all this time it is the part of the nurse to continue to make effective pressure upon the abdomen of the mother—also while he delivers the shoulders—and while he perhaps introduces two fingers into the vagina of the mother to reach the upper jaw of the child and make pressure upon it, so as to depress the chin and facilitate the expulsion of the head.

PRESENTATION OF THE KNEES and PRESENTATION OF THE FEET is identical in its progress with breech cases, and the treatment of breech cases applies to footling presentations, but it is best to avoid pulling on the foot or feet that come down, as it is safer for the child if the lower part of the body is delivered quite slowly. Even if the nurse should in an emergency deliver the child, she should help principally by pressure on the mother’s abdomen.

The only rule that I would have the skilled nurse adopt in regard to these cases, is that it is necessary that she should discover as early as possible if the labor is not a natural one, and if it is unnatural, should obtain the services of a physician as soon as possible. The same rule applies to cases of placenta previa hemorrhage, but I shall have more to say of these hereafter. A case of compound presentation where the hand and arm presents with the head, or in which the feet and hands, or one of each present together, also imperatively demand the services of an experienced accoucheur without delay. The nurse will be impotent to give any efficient help until the doctor arrives.

Presentation of the SUPERIOR EXTREMITIES will receive from me a full and complete description, because I believe that under certain circumstances the nurse should be prepared to operate by turning. As this radical opinion may perhaps be opposed by my medical brethren, I offer the following reasons for it which I consider a sufficient justification.

1. Cases of this class commence with the ordinary symptoms of labor; their peculiar character cannot usually be distinguished until the os is well dilated, and this is the only favorable time to perform the operation of turning.

2. Although in cities and villages generally, a physician’s services can in most instances be immediately obtained, in the country it is not always practicable to obtain them within an hour or two of time.

3. Such knowledge as is necessary for the performance of this operation may be obtained from such description and instruction as can be given in books.

4. There are some women who possess the necessary traits of character, the complete exercise of their faculties, with the perfect coolness which is demanded of the operator in such a case.

5. I do not advocate trusting the operation to a nurse when the services of an accoucheur can possibly be obtained within the proper time.

6. The services of a physician, if obtained one or two hours after the arm is first thrust down in the vagina, may not be of any use because the time for turning is passed.

7. The operation of turning, performed by a properly instructed nurse, does not involve the least danger to the mother or child.

8. The only danger connected with this operation arises from the size of the hand of the operator, and the woman’s hand is small.

9. It is a historical fact that at one period practitioners overrated the performance of turning, and extended its use to unsuitable cases, and after the invention of the forceps, they fell into an opposite error. It is possible that we may be in error if we hold that the nurse cannot be instructed to perform the operation of turning.

10. I do not advise that the nurse should ever attempt to turn in those cases in which the membranes have been long ruptured—the shoulder and arm pressed down into the pelvis, and the uterus contracted around the body of the child. I once succeeded in a case that two experienced physicians had tried in vain for several hours to turn, and I never had very much difficulty in turning, but there have been many cases where excellent operators could not succeed in turning.

In cases of PRESENTATION OF SHOULDER, ARM OR TRUNK, delivery by the natural powers is quite exceptional, though the natural powers have occasionally succeeded in expelling the child. The safety of the mother and child depend upon the early detection of the abnormal position of the fœtus, and upon their receiving proper treatment before labor has been long in progress.

The position of the child is one intermediate between the long and transverse diameters. It may lie with its back towards the abdomen of the mother or with the back towards the spine of the mother, and the head of the child may be towards the right or the left of the mother.

The existence of a shoulder presentation is not commonly suspected until the first examination is made during labor. Suspicion will arise from finding on examination that we are not able to reach the presenting part, and that the os uteri does not dilate as usual, and that when it becomes dilated the bag of membranes protrude of a conical form, but this is common to all malpresentations. When the shoulder has descended a little it is recognized as a round, smooth prominence, rounder than the elbow, and we may be able to reach the axilla, &c. The elbow may be recognized by the sharp prominence of the bone, and the hand can be distinguished from the foot by the fingers being wider apart and more readily separated from each other than the toes, and by the thumb which can be carried across the palm. The situation of the thumb and the aspect of the palm of the hand will mark whether it is the right hand or the left.

As soon as the nurse ascertains or suspects from an external palpation or a vaginal examination, that it is a cross birth she should send for the doctor, who ought to be there as soon as the membranes are ruptured, and the nurse must not be very persistent in making examinations lest she rupture the membranes prematurely. She may perhaps give a small dose of morphine, but I would not advise that she give chloroform as it is not necessary.

The right time to turn the child is when the os uteri is dilated, either before or immediately after the rupture of the membranes, and if a doctor cannot be soon obtained, it is better that a skilled nurse should turn the child, and if she is properly instructed, she should do it carefully and slowly, but without any fear and confidently. She can assure the patient that she will be able in a short time to relieve her sufferings.

In England the ordinary position for turning is on the left side. I prefer that the patient be placed across the bed on her back with her legs drawn up and supported by assistants. I now describe my own mode of operating.

I bare my right arm and hand (sometimes the left), lubricating it freely. If the waters have only recently escaped, and the os be dilated, the operation is performed with ease, especially after we have determined the position of the child.

I press the fingers together in the form of a cone, the thumb between the fingers—slowly and carefully press them into the vagina in an interval between the pains, and constantly and slowly press the hand in, only when the contractions of the uterus remit; never using any force, gently pass the fingers into the os; gently open the fingers a little occasionally to dilate the os sufficiently, and when it is expanded pass the hand into the uterus, make out the presentation accurately, so as to keep my hand to the abdomen of the child; always keep the hand still during a pain; when there is an interval between the pains, carefully search for the feet; when one of the feet is found, clasp the leg at the knee with one finger; flex the leg at the knee so that the finger has a good hold of it, draw it down in the absence of a pain; as the knee approaches the os when it is drawn down over the abdomen of the child, the shoulders and head recede towards the fundus, and when the head has reached the fundus and the knee is brought through the os, the case is converted into a knee presentation, and I deliver slowly but without needless delay—making a little traction during each pain, the management being conducted as in feet presentations, and the whole process being assisted by pressure made on the uterus by my left hand, or by the hand of an assistant.

Possibly these directions will be better understood if I use the language of another who directs:

1. That the patient be placed on her left side near the edge of the bed.

2. The os externum is then to be dilated with the fingers reduced into a conical form, acting with a semi rotary motion of the hand.

3. When the hand is passed through the os externum it must be slowly conducted to the os uteri. We may perforate the membranes with the finger if they are not broken.

4. The hand must then be passed along the thighs and legs of the child until we come to the feet. If both the feet lie together we must grasp them firmly with one hand, but if they are distant from each other we may deliver by one foot.

5. Before we begin to extract we must be sure that we do not mistake a hand for a foot. The feet must be brought down with a slow, waving motion into the pelvis, when we are to wait till the uterus contracts, still retaining them in the hand.

6. The feet are to be brought down with each return of the pain, and the labor may be finished partly by the efforts of the mother and partly by art.

7. If the toes are turned towards the pubis the back of the child is towards the back of the mother which is an unfavorable position.

8. If the toes are towards the sacrum, the back of the child is towards the abdomen of the mother, and this position is advantageous when the head comes to be extracted.

9. When the feet of the child has passed through the os externum, wrap them in a cloth and holding them firm wait till there is a pain, during the continuance of which gently draw down the feet. When the pain ceases we must rest, we merely assisting the efforts of the patient.

10. When the child is brought so low that the funis reaches the os externum, a small portion of it is to be brought out to slacken it, and from this time the operation is to be finished as speedily as it can be with safety, but if the circulation of the funis be undisturbed, there is no occasion for haste as the child is in safety.

11. If the child should stick at the shoulders the arms must be successively brought down.

12. When both the arms are brought down the body of the child must be supported upon our left arm and hand, the fingers on each side of the neck, and if the head should not come easily away, we must introduce the forefinger of one hand into the mouth of the child to render the position of the head more convenient for passing.

12. When a child has been extracted by the feet, the placenta usually separates very easily, but in the management we are to be guided by the general rules.

13. In these cases the child usually needs to be resuscitated, and the nurse should arrange so that hot and cold water may be at hand if required.

In these descriptions of the operation I have mentioned both the back and side as good positions for the mother, because some accoucheurs prefer one position and some the other. Some prefer to have the patient on the hands and knees. But if the nurse have the instructions here given well in her mind, she can operate in either position. If she ascertains at first how the child lies she may sometime reach its abdomen better if she introduces her left hand, but the main point is to proceed slowly and carefully. She should be careful in passing in her hand to change the direction of it in accordance with the pelvic axis, and should not use much force at any time. The danger to the mother is very small indeed; the danger to the child arises, as in breech presentations, from the compression of the funis, which commences about the time the buttocks appear at the os externum. But the safety is only when the operation is performed at the proper time. The nurse must never operate if the services of a physician can be obtained at that time, but when it is necessary she may proceed to turn, doing it slowly and properly, but fearlessly and confidently. If the doctor that is sent for is informed before he arrives that it is a case of hand presentation, he will come dreading the difficulties that he may encounter, and if he can have the satisfaction of knowing when he comes that the woman is safely delivered, he will be exceedingly glad.